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Tonsillectomy is one of the most common operations. Tonsillectomy is also one of the most painful surgical procedures. However, there is still no satisfactory standard for postoperative pain management. Four databases (Cochrane Library, Ovid Technologies, PubMed, Web of Science) were searched for the period from 1908 to 2019. The systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were pooled using random-effects and fixed-effects models. Randomized controlled trials, reviews and meta-analyses were included. Primary outcomes were quantitative pain intensity in the first 24 h after tonsillectomy and on days 1, 3, and 7 postoperatively. The search yielded 1594 publications, of which 111 publications with 7566 patients, both children and adults, could be included. Intraoperative medication with intravenous dexamethasone significantly reduced pain (mean difference [MD] -0.42; 95% confidence interval [CI]: -0.61- -0.24). Among the local anesthetics, only the preoperative injection of levobupivacaine into the tonsillar compartment was able to provide sufficient pain reduction up to three days after tonsillectomy (MD: -1.92; 95% CI: -2.73 - -1.11). Preoperative or intraoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduced pain (MD: -0.75; 95% CI: -0.87- -0.63). Steroids and NSAIDs are an important part of pain management after tonsillectomy. [ABSTRACT FROM AUTHOR]

Botulinum toxin has been an established medication for an increasing number of indications for over 30 years. In addition, there are a number of indications that are not officially authorised, but which, based on the literature, are useful or at least possible as a reserve procedure. In this paper, the current scientific status for the treatment of gonarthrosis with botulinum toxin is presented on the basis of 11 RCTs and several current reviews and meta-analyses. Overall, the indication can now be recognised as a sensible alternative as a reserve procedure in selected individual cases, especially as the established other non-surgical procedures are only convincing to a limited extent according to the current state of scientific knowledge. [ABSTRACT FROM AUTHOR]

Chronical, persistent pain of the shoulder or knee in DJD are especially at the knee mostly treated with the implantation of an artificial joint. Nevertheless there is a considerable percentage of patients that either do not want a replacement or are not suitable therefore. After a long development of looking for purely sensible branches of innervating nerves of the facet joints and the SIJ and treating pain there with an ablation of these nerves with radio frequency in the last 15 years also the ablation of sensible nerves at knee and shoulder was developed and established. The article shows the anatomical situation of theses nerves and the established techniques of treating knee- and shoulder pain with this method. [ABSTRACT FROM AUTHOR]

Background: Low back pain, a common problem worldwide, causes more global disability than any other condition and is associated with high costs to society. This observational registry-based study describes the current trends in the medical treatment of neuropathic low back pain in the Swedish region of Västra Götaland, which has a population of 1.7 million. The study aims to; (1) identify the prevalence of neuropathic low back pain within the study population; (2) to explore the patterns of medical treatment utilization, including the prevalence and distribution of opioids (OG) and analgesics specified for neuropathic low back pain (NG) and (3) to evaluate the long-term trends and changes in medical treatment practice for neuropathic low back pain over the study period. Methods: This study includes a descriptive analysis of aggregated data extracted from the Swedish primary care registry VEGA and the pharmaceutical prescription registry Digitalis between the years 2017 and 2021. The data were stratified by year, age, gender, pharmaceutical code (ATC), and sub-diagnoses and presented as the prevalence of unique patients retrieving prescribed medication within six months before or after a registered diagnosis of neuropathic low back pain. The pharmaceutical codes were furthermore grouped into two groups depending on their mechanism of action; opioid group (OG) and neuropathic group (NG). Results: In all four diagnosis groups, more patients used opioid analgesics than neuropathic analgesics. The greatest difference between the opioid group and neuropathic group was in the lumbar spinal stenosis diagnosis group (67.1% vs. 40.6%), followed by the lumbar root canal stenosis diagnosis (65.9% vs. 44.2%), the nerve root and plexus compressions in intervertebral disc disorders diagnosis (57.5% vs. 40.8%), and lumbago with sciatica diagnosis (38.4% vs. 22.7%). Conclusions: The trends suggest a general increase in the prescription rate and therefore patients' use of neuropathic analgesics for neuropathic pain associated with the studied diagnoses. However, opioid treatment remains the most common. The results indicate that the treatment for neuropathic low back pain needs to be improved. [ABSTRACT FROM AUTHOR]

Purpose: Safe and effective analgesia sub partu is one of the central issues in optimizing vaginal delivery birth experiences. Meptazinol is a common opiate approved for treating labor pain in the first stage of labor. According to the manufacturer, manual meptazinol can be applied intramuscularly or intravenously. The aim of this study was to compare the two application methods in terms of efficacy in pain relief, occurrence of side effects and treatment satisfaction. Methods: 132 patients with singleton term pregnancies and intended vaginal delivery, receiving meptazinol during first stage of labor were included in this prospective cohort study from 05/2020 to 01/2021. We evaluated effectiveness in pain relief and treatment satisfaction using numeric rating scales (NRS) and documented the occurrence of adverse effects. Chi-square test or Fisher exact test were used to compare categorical data and Mann–Whitney U test to compare continuous data between the two treatment groups. Statistical analysis was done by SPSS 27.0. A p value < 0.05 was considered to indicate statistical significance (two tailed). Results: Meptazinol decreased labor pain significantly from a NRS of 8 (IQR 8–10) to 6 (IQR 4.75–8) in both treatment groups with no difference in effectiveness between the groups. Frequency of effective pain reduction of a decrease of 2 or more on the NRS did not differ between groups (39.4% vs 54.5%, p = 0.116), as the occurrence of adverse effects. 12% of the newborns were admitted to NICU, the median NApH was 7.195. Conclusion: Meptazinol significantly reduces labor pain regardless of the method of application: intramuscular or intravenous. According to our data, no preferable route could be identified. The comparably poorer perinatal outcome in our study cohort hinders us to confirm that meptazinol is safe and can be recommended without restrictions. [ABSTRACT FROM AUTHOR]

Rechargeable implantable pulse generators (r-IPGs) have been available for spinal cord stimulation (SCS) claiming to offer a longer service life but demanding continuous monitoring and regular recharging by the patients. The aim of the study (DRKS00021281; Apr 7th, 2020) was to assess the convenience, safety, and acceptance of r-IPGs and their effect on patient lives under long-term therapy. Standardized questionnaires were sent to all chronic pain patients with a r-IPG at the time of trial. Primary endpoint was the overall convenience of the charging process on an ordinal scale from “very hard” (1 point) to “very easy” (5 points). Secondary endpoints were charge burden (min/week), rates of user confidence and complications (failed recharges, interruptions of therapy). Endpoints were analyzed for several subgroups. Data sets n = 40 (42% return rate) were eligible for analysis. Patient age was 57.2 ± 12.6 (mean ± standard deviation) years with the r-IPG being implanted for 52.1 ± 32.6 months. The overall convenience of recharging was evaluated as “easy” (4 points). The charge burden was 112.7 ± 139 min/week. 92% of the patients felt confident recharging the neurostimulator. 37.5% of patients reported failed recharges. 28.9% of patients experienced unintended interruptions of stimulation. Subgroup analysis only showed a significant impact on overall convenience for different models of stimulators (p < 0.05). Overall, SCS patients feel confident handling a r-IPG at high rates of convenience and acceptable effort despite high rates of usage-related complications. Further technical improvements for r-IPGs are needed. [ABSTRACT FROM AUTHOR]

Background: Oxycodone entered the market in Germany in 1998 as an oral opioid analgesic, after it had been withdrawn from the market in 1990. Today it is the most prescribed oralWorld Health Organization (WHO) level 3 opioid, although its analgesic effect is no different from that of other opioid analgesics. In 2017, it was prescribed more often than ibuprofen in Germany. Objectives: What is the explanation for this rise? Methods: Scoping literature review, evaluation of pharmaceutical statistics and guidelines, discussion of recommendations. Results: The rise of oxycodone prescriptions is not due to its pharmacological or medicinal properties. The causes of its frequent prescription are the marketing efforts of a pharmaceutical company. Medical sources of information have been influenced or changed on a large scale. Conclusions: The rise in the popularity of prescribing oxycodone was possible because physicians have paid too little attention to the quality of sources providing pharmacological information. [ABSTRACT FROM AUTHOR]

Botulinumtoxin wurde vor über 30 Jahren als Medikament eingeführt, das Indikationsspektrum hat sich seitdem kontinuierlich weiterentwickelt. Mittlerweile existiert eine Reihe von Indikationen im Bereich Augenheilkunde, HNO, Neurologie, Urologie und fachübergreifenden Gebieten. Das Toxin ist das stärkste bekannte Gift, das klinische Erscheinungsbild einer Vergiftung wird Botulismus genannt mit verschiedenen Entstehungsformen, klinischen Symptomatiken und Prognosen. Hierbei handelt es sich um ein Exotoxin, vorwiegend von Clostridium botulinum produziert. Der Wirkmechanismus besteht in der strukturell irreversiblen und durch Neuausbildung zeitlich befristeten Blockade der Freisetzung von Acetylcholin in den synaptischen Spalt an der motorischen Endplatte und am Drüsengewebe. Neueren Datums sind Erkenntnisse, dass für die Reizweiterleitung relevante Stoffe wie v.a. CGRP gehemmt werden, mit der Folge einer verringerten sensiblen Weiterleitung und damit auch der Reduktion der peripheren und nachfolgend der zentralen Schmerzsensibilisierung. In der EU erhältlich sind vorrangig 3 verschiedene Toxintypen mit unterschiedlichen zugelassenen Indikationen, ein 4. Typ wurde jetzt in den Vertrieb genommen, ein 5. Typ besitzt die Zulassung. Gerade für einen In-Label-Use ist zu beachten, dass nicht alle Präparate für alle Indikation zugelassen sind, manchmal existieren noch weitere Begrenzungen, die Zulassung kann sich auch bei identischen Präparaten länderspezifisch unterscheiden. Daneben werden diese Präparate auch außerhalb der Zulassung angewendet (Off-Label-Use). Die Anwendung kann dann infrage kommen, wenn die herkömmlichen Therapien nicht erfolgreich, mit größeren Nebenwirkungen behaftet oder kontraindiziert sind. Hierbei handelt es sich einerseits um Therapien mit den offiziellen Zulassungen ähnlicher Indikationen, aber auch um Anwendungen in anderen Bereichen. Die Indikationsstellung wird umso leichter, je besser sich die wissenschaftliche Basis darstellt. Hierbei kann man im orthopädisch-unfallchirurgisch-schmerztherapeutischen Bereich 3 Gruppen unterscheiden. Sinnvolle Indikation sind myofasziale Triggerpunkte im Bereich HWS/BWS und Schulterregion inkl. Cervikocephalgien, Epikondylitis humeroradialis, Plantarfasciitis und Trigeminusneuralgie. Mögliche Indikationen mit eingeschränkter wissenschaftlicher Basis sind myofasziale Triggerpunkte im Bereich LWS, Bruxismus, Postzosterneuralgie, extraartikuläre Muskelentspannung bei Coxarthrose und vorderem Knieschmerz, Gonarthrose, Schulteraffektionen und Spannungskopfschmerzen. Einzelfallindikationen sind u.a. Achillessehnenruptur, Morton-Neurom, diabetische Neuropathie, Reizzustände nach Knieendoprothese, Stumpfschmerzen und Anpassungsprobleme bei Exoprothesen. Basis für die Anwendung von Botulinumtoxin ist eine ausreichende Ausbildung, hier existiert eine spezielle Kursserie der IGOST. Botulinum toxin was introduced as a drug over 30 years ago, and the range of indications has developed continuously since then. There are now a number of indications in ophthalmology, ENT, neurology, urology and interdisciplinary. The toxin is the strongest known poison, the clinical appearance of a poisoning is called botulism, with different forms of development, clinical symptoms and prognoses. This is an exotoxin, predominantly produced by Clostridium botulinum. The mechanism of action is the structurally irreversible and temporary blockade of the release of acetylcholine into the synaptic cleft at the motor endplate and glandular tissue. More recent findings indicate that substances relevant for stimulus transmission, such as CGRP in particular, are inhibited, with the consequence of reduced sensitive transmission and thus also a reduction in peripheral and subsequently central pain sensitization. Three different toxin types with different approved indications are primarily available in the EU, a 4th type has now been put on the market and a 5th type has been approved. Especially for an in-label use it has to be considered that not all preparations are approved for all indications, sometimes there are further limitations, the approval can differ country specific even for identical preparations. In addition, these preparations are also used outside of the approval (off-label use). Off-label use may be considered when conventional therapies are unsuccessful, have major side effects, or are contraindicated. On the one hand, these are therapies with indications similar to the official approvals, but also applications in other areas. The better the scientific basis, the easier it is to determine the indication. In this context, three groups can be distinguished in the orthopedic-accident surgery-pain therapy area. Possible indications are myofascial trigger points in the cervical spine and shoulder region, including cervicocephalgia, epicondylitis humeroradialis, plantar fasciitis and trigeminal neuralgia. Possible indications with limited scientific basis are myofascial trigger points in the lumbar spine, bruxism, post zoster neuralgia, extraarticular muscle relaxation in coxarthrosis and anterior knee pain, gonarthrosis, shoulder afflictions and tension-type headache. Individual case indications include Achilles tendon rupture, Morton's neuroma, diabetic neuropathy, post knee arthroplasty irritation, residual limb pain and fitting problems with exoprostheses. The basis for the application of botulinum toxin is a sufficient training, here exists a special course series of the IGOST. [ABSTRACT FROM AUTHOR]

A robust cell-free platform technology, ribosome display in combination with cloning, expression, and purification was utilized to develop single chain Fragment variable (scFv) antibody variants as pain therapy directed at the mouse cholecystokinin B (CCK-B) receptor. Three effective CCK-B peptide-specific scFvs were generated through ribosomal display technology. Soluble expression and ELISA analysis showed that one antibody, scFv77-2 had the highest binding and could be purified from bacterial cells in large quantities. Octet measurements further revealed that the CCK-B scFv77-2 antibody had binding kinetics of KD = 1.794 × 10–8 M. Molecular modeling and docking analyses suggested that the scFv77-2 antibody shaped a proper cavity to embed the whole CCK-B peptide molecule and that a steady-state complex was formed relying on intermolecular forces, including hydrogen bonding, electrostatic force, and hydrophobic interactions. Thus, the scFv antibody can be applied for mechanistic intermolecular interactions and functional in vivo studies of CCK-BR. The high affinity scFv77-2 antibody showed good efficacy with binding to CCK-BR tested in a chronic pain model. In vivo studies validated the efficacy of the CCK-B receptor (CCK-BR) scFv77-2 antibody as a potential therapy for chronic trigeminal nerve injury-induced pain. Mice were given a single dose of the CCK-B receptor (CCK-BR) scFv antibody 3 weeks after induction of a chronic trigeminal neuropathic pain model, during the transition from acute to chronic pain. The long-term effectiveness for the reduction of mechanical hypersensitivity was evident, persisting for months. The anxiety- and depression-related behaviors typically accompanying persisting hypersensitivity subsequently never developed in the mice given CCK-BR scFv. The effectiveness of the antibody is the basis for further development of the lead CCK-BR scFv as a promising non-opioid therapeutic for chronic pain and the long-term reduction of chronic pain- and anxiety-related behaviors. [ABSTRACT FROM AUTHOR]

Prompt and appropriate treatment of chronic low back pain (cLBP) is of the utmost importance for preventing relevant disability, high burden of disease, and increasing costs for the healthcare system. Recently, the concept of functional impairment has been associated with any type of chronic pain, and mounting attention has been paid to extending the aims of treatment beyond mere pain remission, including restoration of working capacity, everyday functioning, mobility, and quality of life. Nevertheless, a shared definition of functionality is still lacking. Notably, different specialists involved in the treatment of cLBP such as general practitioners, orthopedists, pain therapists, and physiatrists, and patients themselves have different opinions on what "functional impairment" actually means. On these premises, a qualitative interview study was performed to investigate how the concept of "functionality" is interpreted by different specialists involved in the management of cLBP, and by patients. Overall, all different specialists agreed that functionality should be assessed in clinical practice. However, in spite of several instruments available for evaluating functionality, no homogeneity of behavior is observable. [ABSTRACT FROM AUTHOR]

This study aimed to verify the comparative effectiveness of shock wave therapy versus therapeutic exercise, including the possibility of combining both therapies, in patients who did not respond to the first treatment. A prospective randomized clinical trial was carried out, predicting the possibility of a cross-over between the two treatment options, with patients who did not respond to either treatment. Treatments were, respectively, eccentric therapeutic exercise consisting of 30 min sessions of stretching and strengthening exercises, 5 days a week for 4 weeks (Groups A and D) and Extracorporeal Shock Waves Therapy (ESWT) according to a protocol of three sessions, one per week, each of 2000 pulses at a 4 Hz frequency and administering an energy flux density (EFD) varying between 0.03 mJ/mm2 and 0.17 mJ/mm2 (Groups B and C). Patients were evaluated at baseline (T0), 2 (T1), 4 (T2) and 6 months (T3) after the last session, using the Numeric Rating Scale (NRS), Low Extremity Functional Scale (LEFS) and Roles and Maudsley Scale (RMS). The whole study population demonstrated a progressive clinical reduction in pain according to NRS, a recovery from disability according to LEFS and a perception of recovery according to RMS within 6 months, with no significant differences between the four protocols (exercise; ESWT; exercise + ESWT; and ESWT + exercise). Both therapies are therefore valid options in patients with trochanteritis; the combination of the two therapies could be evaluated for those patients who do not respond to the single treatment. [ABSTRACT FROM AUTHOR]

Patients suffering from chronic pain may respond differently to analgesic medications. For some, pain relief is insufficient, while others experience side effects. Although pharmacogenetic testing is rarely performed in the context of analgesics, response to opiates, non-opioid analgesics, and antidepressants for the treatment of neuropathic pain can be affected by genetic variants. We describe a female patient who suffered from a complex chronic pain syndrome due to a disc hernia. Due to insufficient response to oxycodone, fentanyl, and morphine in addition to non-steroidal anti-inflammatory drug (NSAID)-induced side effects reported in the past, we performed panel-based pharmacogenotyping and compiled a medication recommendation. The ineffectiveness of opiates could be explained by a combined effect of the decreased activity in cytochrome P450 2D6 (CYP2D6), an increased activity in CYP3A, and an impaired drug response at the µ-opioid receptor. Decreased activity for CYP2C9 led to a slowed metabolism of ibuprofen and thus increased the risk for gastrointestinal side effects. Based on these findings we recommended hydromorphone and paracetamol, of which the metabolism was not affected by genetic variants. Our case report illustrates that an in-depth medication review including pharmacogenetic analysis can be helpful for patients with complex pain syndrome. Our approach highlights how genetic information could be applied to analyze a patient's history of medication ineffectiveness or poor tolerability and help to find better treatment options. [ABSTRACT FROM AUTHOR]

Background: Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS. Methods: Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included. Results: Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases. Conclusions: Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality. [ABSTRACT FROM AUTHOR]

Introduction: The use of paracetamol for pain relief in pregnancy is common. However, the influence of paracetamol on the perinatal adaptation of high‐risk infants has not been studied. These data are important for safety, since another inhibitor of prostaglandin synthesis is harmful to infants born very preterm and increases serious morbidity. We studied whether the use of paracetamol had an adverse influence on neonatal adaptation and the outcomes of infants during the first hospitalization. Material and Methods: We studied the patient records of high‐risk mothers and their infants born before 32 weeks of gestation for multiple variables over a period of 84 months in Oulu University Hospital, a regional tertiary care hospital caring for high‐risk deliveries and providing neonatal intensive care. In a matched cohort setting, the exposition was defined as paracetamol use <24 h before childbirth. The controls had consumed no paracetamol up to 1 week before delivery. Infants with major anomalies were excluded. The primary outcome was defined as the need for early interventional treatments for the preterm infants. Outcomes during the first hospitalization were also studied. Results: Altogether, 170 fetuses from 149 mothers were exposed to paracetamol during the study period. The control population, delivering during the same period, consisted of 118 non‐exposed fetuses from 104 mothers. Among them, the mothers were pairwise matched according to their medications, amniotic fluid leakage time, clinical infections, and delivery mode. After matching, 72 mothers/group remained, resulting in 88 paracetamol‐exposed infants and 85 controls. No perinatal adverse reactions were detected. There were no differences in either circulatory support during the first postnatal day or in the risk for major diseases during the first hospitalization. Paracetamol‐exposed infants needed fewer acute delivery room therapies (51.1% vs 65.9%, mean difference −14.89; 95% confidence interval −0.29 to −0.003). Maternal total paracetamol dose in the 1 week before delivery correlated positively with Apgar scores. Conclusions: Antenatal paracetamol given within 24 h before birth had no adverse effects on extremely or very preterm infants. The long‐term safety of paracetamol and the potential acute benefits for preterm infants during perinatal transition remain to be proven in larger, prospective settings. [ABSTRACT FROM AUTHOR]

Background: We assessed the efficacy and safety of the Xiaoketongbi Formula (XF) vs. pregabalin in patients with painful diabetic neuropathy (PDN). Methods: Patients with PDN (n = 68) were included in a single‐center, randomized, single‐blind, double‐dummy, parallel controlled clinical trial. The primary outcome was the change in the Brief Pain Inventory for Diabetic Peripheral Neuropathy (BPI‐DPN). Secondary outcomes evaluated included the reduction of BPI‐DPN >50%, changes in the numeric rating scale‐11 (NRS‐11) score for pain, Daily Sleep Interference Diary (DSID), Patient Global Impression of Change (PGIC), nerve conduction velocity (NCV), and adverse events. Results: After 10 weeks of treatment, the BPI‐DPN score reduced from 42.44 ± 17.56 to 26.47 ± 22.22 and from 52.03 ± 14.30 to 37.85 ± 17.23 in the XF and pregabalin group (Ps < 0.001), respectively. The difference in the absolute change in BPI‐DPN score between both groups was −1.79 (95% CI: −9.09, 5.50; p = 0.625). In the XF and pregabalin groups, 44.1% (15/34) and 20.6% (7/34) of patients reported a BPI‐DPN reduction >50% (p = 0.038), respectively. There were no significant differences between groups in NRS‐11 and DSID (Ps > 0.05). A significantly greater number of patients in the XF group felt "significantly improved" or "improved" than in the pregabalin group (35.3% (12/34) vs. 11.8% (4/34), p = 0.045). The absolute change in motor nerve conduction velocity of the right median nerve was significantly different between both groups (XF group 0.7 ± 2.3 vs. pregabalin group −2.2 ± 4.1, p = 0.004). No serious adverse events were reported in either group. Conclusions: XF is equivalent to pregabalin in reducing pain symptoms and improves the quality of life in patients with PDN. In addition, XF has the potential to improve nerve function by increasing NCV. [ABSTRACT FROM AUTHOR]

Background: Labor pain is difficult to measure. The aim of this proof-of-concept study is to implement and test a questionnaire assessing pain sensation during and after vaginal deliveries. Its key aspect is a highly standardized survey of patient-reported outcome (PRO) by staff not involved in routine care. Methods: Between January and November 2015 339 women were assessed 24–48 h after spontaneous or operative-vaginal delivery of a singleton. German language skills were a prerequisite to participate. The test–retest reliability was calculated in 38 women 24–36 and 48–72 h postpartum between July and October 2017. Primiparae after spontaneous delivery and multiparae with no history of operative deliveries were compared in a subgroup analysis. Results: Maximum labor pain and post-partum pain were reported a median of 9 [8–10] and 4 [3–6]. Higher ratings were associated with younger age, higher gestational ages, infant's biometrics, and the duration of laboring. Only regional analgesia tended to reduce pain perception (NRS 8 vs. 9). Higher-degree injuries were associated with less pain postpartum. The questionnaire proved to be reliable in most aspects (Cronbach's α > 0.6 for 19/21 questions) and showed an acceptable content and criterion validity (Cohen correlation > ± 0.3, interrelation between items). Conclusion: Labor is a very painful experience, irrespective of previous obstetric history. Ratings indicate inadequateness of treatment except for patients receiving preventive postoperative pain management. Systematic postpartum pain assessment, hence, is still a pending issue. Adjustments will be made concerning language skills and specific questions on effectiveness of analgesia otherwise good reliability and validity of the questionnaire were proven. [ABSTRACT FROM AUTHOR]

Background: Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain - Army soldiers returning from deployment.Methods: Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008-2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures.Results: In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care.Conclusions: Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management. [ABSTRACT FROM AUTHOR]

Pain is a complex perceptual phenomenon. Coordinated activity among local and distant brain networks is a central element of the neural underpinnings of pain. Brain oscillatory rhythms across diverse frequency ranges provide a functional substrate for coordinating activity across local neuronal ensembles and anatomically distant brain areas in pain networks. This review addresses parallels between insights from human and rodent analyses of oscillatory rhythms in acute and chronic pain and discusses recent rodent-based studies that have shed light on mechanistic underpinnings of brain oscillatory dynamics in pain-related behaviors. We highlight the potential for therapeutic modulation of oscillatory rhythms, and identify outstanding questions and challenges to be addressed in future research. Brain oscillatory rhythms across specific frequency bands are altered during acute and chronic pain in rodent and human studies, with consensus on changes in high frequency (gamma) oscillations. There is less consensus among human and rodent studies on changes in low frequency oscillations in acute and chronic pain. Rodent analyses support a key functional role for gamma oscillations in acute pain perception and aversion and in modulation of hypersensitivity in chronic pain. Fast-spiking GABAergic interneurons sculpt local cortical oscillatory rhythms and modulate the activity of other cortical and subcortical areas involved in negative affect and descending modulation of nociception. Insights are emerging on diverse ion channels and gap junction proteins in local and distant oscillatory rhythms that provide a substrate for pharmacological modulation of oscillations in pain therapy. [ABSTRACT FROM AUTHOR]

Medicine pain therapy of musculoskeletal complaints are often not promising because of complex causes and tendency to chronize. On the other hand, it is essential to acute complaints, given its light availability and short-term effects. All the more it requires the treatment of the patients to be fully aware that this is symptomatic therapy, taking thoroughly into account the effectiveness and side effects, dosage and patient education. [ABSTRACT FROM AUTHOR]

Background: The Combined Mandibulectomy and Neck Dissection (COMMANDO) surgery results in severe postoperative pain and requires multimodal analgesia (MMA) for its management. We speculated that the erector spinae plane block (ESPB) which is the ultrasound (US)-guided regional technique and has been used in various types of surgeries due to its analgesic benefits could be used as an effective analgesic adjunct in COMMANDO surgery. Case presentation: We report a case of a 68-year-old female patient who underwent left side COMMANDO surgery for carcinoma cheek. She was given an ultrasound-guided left erector spinae plane block (ESPB) in the preoperative period with catheter insertion at T3 (3rd thoracic vertebral level). Two boluses of local anesthetic were given each with 10 ml 0.25% ropivacaine one before and one after surgery, and then, the infusion was started with a volumetric pump. The ESPB provided effective intraoperative as well as postoperative pain relief without any side effects. Conclusion: US-guided ESPB could be used as a potential opioid-sparing multimodal analgesic in head and neck surgeries based on the pain relief provided and the spread of contrast on imaging. This hypothesis needs to be explored in the form of case series and adequately powered randomized controlled trials. [ABSTRACT FROM AUTHOR]

Objective: To alleviate pain after tonsillectomy (TE) with escalating gradual treatment protocols in a prospective trial.Materials& Methods: Following TE, 83 consecutive adult patients were treated with two different four-staged escalating analgesic protocols. Metamizole served as basic medication in protocol 1 (PT1; n = 44), whereas with protocol 2 (PT2; n = 39) ibuprofen was applied as baseline analgesic. Both protocols were escalated according to the patient´s needs to metamizole and ibuprofen vice versa and additional weak to strong opioids. The primary efficacy endpoint was defined as the minimum and maximum pain as well as pain on ambulation (NRS, 0-10). Secondary endpoints comprised analgesic score, patient satisfaction and treatment-related side-effects.Results: Both patient groups exhibited similar demographic characteristics (PT1: Ø 28.8 years; 64% ♀ and PT2: Ø 26.6 years; 56% ♀). Maximum pain (6.7 ± 1.9 vs. 7.6 ± 1.6, t(81) = -2.254, p = 0.027) and pain on ambulation (5.0 ± 1.8 vs. 5.8 ± 1.8, t(81) = -2.114, p = 0.038) were significantly higher with PT2. 68.2% of patients with PT1 needed an escalation of analgesic treatment compared to 100% with PT2 (p < 0.001). The opioid consumption was also significantly higher with PT2 (43.2% vs. 71.8%, p < 0.001). There were no significant differences regarding functional impairments, side-effects and patient satisfaction (7.0 ± 2.0 vs. 7.4 ± 2.4, t(79) = -0.897, p = 0.373).Conclusion: Both treatment protocols yielded in a high degree of patient satisfaction but dissatisfactory pain relief following TE. Metamizole can be recommended as a basic medication allowing for improved pain relief. Reported pain intensities were independent of the amount of opioid intake. Further research is mandatory to standardize and improve analgesic treatment after TE. [ABSTRACT FROM AUTHOR]

The article presents discovery of opioid analgesics, their marketing, as well as notable names connected with this history. [ABSTRACT FROM AUTHOR]

Context: Foam rolling (FR) is considered an effective postexercise modality for reducing delayed-onset muscle soreness and enhancing recovery of muscle function. However, the effects of FR on muscle and joint proprioception have not been investigated. Objective: To examine the effects of FR on muscle and joint proprioception after an intense exercise protocol. Design: Controlled laboratory study. Setting: University-based laboratory. Patients or Other Participants: A total of 80 healthy, physically active male students were randomly assigned to either the FR (n = 40; age = 22.8 ± 3.3 years, height = 176.4 ± 5.3 cm, mass = 74.2 ± 6.4 kg) or passive-recovery (PR; n = 40; age = 23.0 ± 3.2 years, height = 178.1 ± 5.5 cm, mass = 74.6 ± 6.2 kg) group. Intervention(s): Participants in both groups performed 4 sets of 25 repetitions of voluntary maximal eccentric contractions at 608/s from 208 to 1008 of knee flexion to induce exercise- induced muscle damage. The exercise was followed by either PR or 2 minutes of FR immediately (1 hour) and 24, 48, and 72 hours postexercise. Main Outcome Measure(s): Muscle soreness, pressure- pain threshold, quadriceps-muscle strength, joint position sense, isometric force sense, and threshold to detect passive movement at baseline and immediately, 24, 48, and 72 hours postexercise after FR. Results: Foam rolling resulted in decreased muscle pain, increased pressure-pain threshold, improved joint position sense, attenuated force loss, and reduced threshold to detect passive movement compared with PR at 24 and 48 hours postexercise. Conclusions: Foam rolling postexercise diminished de- layed-onset muscle soreness and improved recovery of muscle strength and joint proprioception. These results suggested that FR enhanced recovery from exercise-induced damage. [ABSTRACT FROM AUTHOR]

Background Given the unacceptably high miss rates of non-image-guided injections into the sacroiliac joint, either fluoroscopy or ultrasound is recommended for guidance. The real success rate of both techniques was assessed by cadaver dissection. Methods Twenty bodies donated to science (40 joints: 15 female and 5 male) were investigated bilaterally. Fluoroscopy and a lower ultrasound-guided approach were performed in 10 bodies each. Conditions during puncture, the subjective feeling of the needle being intra-articular, and, for fluoroscopic guidance, the intra-articular spread of the contrast were assessed. First, 0.5 cc of Iopamidol was injected, followed by 2 mL of red-colored latex. The spread was investigated by dissection via anterior opening of the sacroiliac joint and the dorsal ligaments. Results Ultrasound guidance was used in 1/20 (5%, 95% CI = 0.9–23.6%) intra-articular injections. In 19/20 (95%, 95% CI = 0.9–23.6%) cases, latex spread in the interosseous sacroiliac ligament was used. Conditions of structural visibility were classified as good in 11/20 (55%, 95% CI = 34.2–74.2%) cases, puncture condition as good in 16/20 (80%, 95% CI = 58.4–91.9%) cases, and subjective feeling of the needle being intra-articular was present in 10/20 (50%, 95% CI = 34.2–74.2%) cases. Fluoroscopy showed an intra-articular injection in 10/20 (50%, 95% CI = 34.2–74.2%) cases. The structure visibility in fluoroscopy was good in 9/20 (45%, 95% CI = 25.8–65.8%), puncture conditions good in 8/20 (40%, 95% CI = 21.9–61.3%), intra-articular contrast spread visible in 10/20 (50%, 95% CI = 34.2–74.2%), and subjective feeling of being intra-articular was present in 17/20 (85%, 95% CI = 64.0–94.8%) cases. Conclusions Fluoroscopy clearly showed a higher success rate of intra-articular sacroiliac joint injection. [ABSTRACT FROM AUTHOR]

Background: Acute pain is a common reason for calling emergency medical services (EMS) and can require medication depending on the pain intensity. German EMS personnel feel strong pressure to reduce a patient's pain but are restricted by law. Currently, German federal law only allows the administration of opioid-containing drugs by or on the order of a physician, while in other European countries (e.g. Switzerland and The Netherlands) the administration of opioid-based analgesia by trained and certified paramedics is common practice. Consequently, a patient in Germany experiencing acute pain needs the attendance of an emergency physician in EMS missions. According to international standards pain reduction on the numeric rating scale (NRS) score by ≥2 or a NRS score ≤4 at the end of the patient transport is considered to be adequate.Objective: Comparison of two different algorithm-based concepts for analgesia with consultation of a physician analyzing the efficacy, tolerance and safety of application.Material and Methods: In a retrospective cohort study in two different regions, two physician-supported algorithm-based analgesia concepts, a call back-supported concept (EMS Schleswig-Holstein: RKiSH) and a tele-EMS physician-based concept (EMS Aachen: RDAC), were compared over 2 years. The call back-supported concept is based on specific algorithms and certification of EMS personnel. In Aachen, the tele-EMS physician is integrated into the routine EMS system and includes immediate vital data transmission.Results: Over a period of 2 years call back-supported analgesia was administered in 878 cases (2016: 428, 2017: 450) and telemedically assisted analgesia was used in 728 cases (2015: 226, 2016: 502). Call back vs. telemedicine: initial NRS scores were 9 (8-10) and 8 (6-9), respectively (p < 0.0001); NRS scores were reduced by 4 (3-5) and 5 (3-6), respectively (p = 0.0002), leading to mean NRS scores of 4 (3-6) vs. 3 (2-4), respectively (p < 0.0001) at patient handover/emergency room arrival. Clinically relevant pain reduction was achieved in both groups. Complete NRS documentation was conducted in 753 (85.8%) vs. 673 (92.4%) cases, respectively, p = 0. Severe adverse events did not occur in either of the groups.Conclusion: The administration of analgesia by EMS personnel with teleconsultation of a physician is effective and has a low rate of complications, particularly morphine. Overall, algorithm-based call back-supported as well as telemedically supported analgesia concepts based on regular training improve the management of pain in the prehospital setting. In addition, the resources of the emergency physician remain available for life-threatening emergencies. The training, certification and supervision of EMS personnel is very important in both systems to ensure the best pain management care and patient safety. Adjustments to the federal law on the administration of analgesics would facilitate the realization of algorithm-based concepts by paramedics as pain reduction could be performed with delegation by a medical director without consulting another physician. [ABSTRACT FROM AUTHOR]

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals. [ABSTRACT FROM AUTHOR]

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals. [ABSTRACT FROM AUTHOR]

Summary Objectives Acute pain in sports tells us what not to do. Persisting pain limits the athletes' activity and threatens his career. The reduction of pain is sought being highly beneficial for the sportsman, as it is shown that pain has only a weak connection to injury but a strong connection to the body image. Thus, pain therapy in sports medicine is a primary need of the athlete. Principle treatment goals are pain relief and return to play as quick as possible. Therapies in sports should primarily focus on conservative than on invasive approaches, with drugs being avoided as far as possible. There is a broad range of treatment approaches that could be applied in concert based on scientific and clinical decision making to reduce symptom severity, pain-associated dysfunction, and the risk of pain to be a tremendous cut in an elite athlete's career. Knowledge on this non-pharmacologic conservative pain medicine should not be restricted to health professionals, but the whole entourage of the athlete. This review highlights the current evidence with a focus on recreational and elite athletes. Based on their clinical evidence, it is hands-on techniques that can be recommended (Grade A: nerve blocks and injection techniques, ultrasound and laser therapy, manipulation mobilization, massage and traction; Grade B: acupuncture and dry needling). The occurrence of possible side-effects is, as far as reported, very unlikely. However, the methodological quality of the majority of retrieved studies limits the overall generalizability. Conclusion Conservative non-pharmacologic therapies reflect an adequate strategy to relief pain in elite athletes. Chronic states of pain reflect more complex scenarios requiring further comprehensive techniques. Future research should thus also address multimodal approaches combining several of the mentioned therapies. [ABSTRACT FROM AUTHOR]

Acute pain caused by surgery, which is strictly related to direct tissue damage, is the main cause of patient's discomfort in the postoperative period. Not only does untreated or insufficiently treated pain lead to suffering of the patient, but it is also the cause of many complications and disorders, both metabolic, hormonal and immunological. It may also result in pathological changes in its perception, e.g. allodynes. Pre-emptive analgesia is a therapeutic treatment that is initiated before the onset of a pain stimulus (nociceptive stimulus). The concept of pre-emptive analgesia aims to prevent and completely block pain signals from surgical wounds from the very first incision of the skin. This method aims to reduce the physiological consequences of nociceptive transmission induced by the procedure, including both the severity of postoperative pain and the possibility of converting acute pain into chronic pain. The following paper presents the latest scientific evidences and results of clinical trials evaluating the effectiveness of pre-emptive analgesia, as well as its relation to the concept of preventive analgesia. [ABSTRACT FROM AUTHOR]

After intensive care unit (ICU) treatment, the recollection of experienced pain is one of the most burdensome aftermaths. In addition, pain has several negative physiological consequences. The majority of patients report moderate to severe pain while being treated on an ICU, often caused by diagnostic or therapeutic procedures. Pain and its functional consequences during ICU treatment should therefore be systematically recorded and treated. Due to their high analgesic potency, pharmacological pain therapy focuses on opioids; however, gastrointestinal motility disturbance and development of tolerance are disadvantages. When applying non-opioids, such as non-steroidal anti-inflammatory drugs (NSAID) and paracetamol, attention should be paid to their possible organ toxicity. Ketamine and α2-antagonists can complement the analgesic concept. Analogous to its perioperative administration, intravenous lidocaine in intensive care seems acceptable because of a favorable impact on opioid requirements and gastrointestinal motility. When using regional anesthesia the positive therapeutic effect and the possible complications need to be carefully weighed. Non-pharmaceutical procedures, especially transcutaneous electrical nerve stimulation (TENS), have proven successful in postoperative pain management. Even if only limited data from intensive care are available, a therapeutic attempt seems justifiable because of the low risk of complications. [ABSTRACT FROM AUTHOR]

Objectives of the study were to compare the effects of a single bout of preventive or regenerative foam rolling (FR) on exercise-induced neuromuscular exhaustion. Single-centre randomised-controlled study was designed. Forty-five healthy adults (22 female; 25±2 yrs) were allocated to three groups: 1) FR of the lower limb muscles prior to induction of fatigue, 2) FR after induction of fatigue, 3) no-treatment control. Neuromuscular exhaustion was provoked using a standardized and validated functional agility short-term fatigue protocol. Main outcome measure was the maximal isometric voluntary force of the knee extensors (MIVF). Secondary outcomes included pain and reactive strength (RSI). Preventive (-16%) and regenerative FR (12%) resulted in a decreased loss in MIVF compared to control (-21%; p < 0.001) five minutes after exhaustion. Post-hoc tests indicated a large-magnitude, non-significant trend towards regenerative foam rolling to best restore strength (Cohen's d > 0.8, p < 0.1). Differences over time (p < 0.001) between groups regarding pain and RSI did not turn out to be clinically meaningful. A single bout of foam rolling reduces neuromuscular exhaustion with reference to maximal force production. Regenerative rather than preventive foam rolling seems sufficient to prevent further fatigue. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this prospective, randomised study was to examine the feasibility and clinical outcome of balloon sacroplasty and radiofrequency sacroplasty.Methods: In 40 patients with a total of 57 sacral fractures, CT-guided cement augmentation was performed by means of BSP or RFS. For BSP, the balloon catheter was inflated and deflated in the fracture zone, and the hollow space, thus, created was then filled with PMMA cement. For RFS, the spongious space in the fracture zone was initially extended using a flexible osteotome, and the highly viscous PMMA cement, activated by radiofrequency, was then inserted into the prepared fracture zone. Pain intensity was determined on a VAS before the intervention, on the second day, and 6, 12 and 18 months after the intervention. The results were tested for significance by means of paired Wilcoxon rank-sum tests and Mann-Whitney U tests.Results: BSP and RFS were technically fully feasible in all patients. An average of 6.3 ml cement per fracture was inserted in the BSP group and an average of 6.1 ml per fracture in the RFS group. Leakage could be ruled out for both procedures. The mean pain score on the VAS before the intervention was 8.6 ± 0.55 in the BSP group and 8.8 ± 0.58 in the RFS group. On the second postoperative day, a significant pain reduction was seen (p < 0.001), with an average value of 2.5 (BSP ± 0.28, RFS ± 0.38) for both groups. After 6 (12; 18) months, these values were stable for the BSP group at 2.3 ± 0.27 (2.3 ± 0.24; 2.0 ± 0.34) and for the RFS group at 2.4 ± 0.34 (2.2 ± 0.26; 2.0 ± 0.31). With regard to pain, exceedance probability values of p = 0.86 (6 months), p = 0.94 (12 months) and p = 1 (18 months) were seen, so that neither treatment method leads to differences in results.Conclusions: BSP and RFS are interventional, minimally invasive procedures that enable reliable cement augmentation and achieve equally good clinical outcomes in the medium term. [ABSTRACT FROM AUTHOR]

Introduction: In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically associated with severe disabling pain. The objective of the present study was to examine the feasibility of cement augmentation by CSP, to determine post-interventional leakages and other complications, and to present the outcome of pain over the course of 18 months. Materials and methods: In 23 patients (20 women and 3 men) with an average age of 81.3 (71-92) years, a total of 41 sacral fractures were detected by MRI, 5 of them unilateral and 18 bilateral. Conservative treatment initially performed over a period of 3 weeks did not bring any satisfactory reduction in the severe disabling pain. The indication for intervention was established after an interdisciplinary case conference. The intervention was performed under intubation anaesthesia. Single-shot antibiotic prophylaxis was given routinely immediately prior to the intervention. Under sterile conditions, a Jamshidi needle was then advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. High-viscosity PMMA cement was then inserted discontinuously with the aid of a pressure gauge under low-dose CT control. Cement leakages were determined in the CT image on the day after the intervention, all cement outside of the cortical boundary being rated as a leakage. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and 6, 12, and 18 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to rate their satisfaction after 6 and 18 months. Results: CSP was technically feasible in all patients. In the control CT scan, sufficient cement distribution and interlocking with vital bone were found along the course of the fracture in the sacrum. An average of 6.0 ± 0.83 ml of cement was inserted per fracture. Leakage was found in 5 of 41 (12.2%) of the fractures treated, although none were symptomatic. The mean pain score on the VAS was 8.8 ± 0.59 before the intervention, a significant pain reduction ( p < 0.0005) was seen on the second post-operative day, with an average value of 2.1 ± 0.36, and this was stable at 2.2 ± 0.28 after 6, 2.3 ± 0.31 after 12, and 2.2 ± 0.41 after 18 months. Now that they no longer experienced disabling pain, all of the patients were fully remobilised and discharged back home. A high level of patient satisfaction was found after 6 and 18 months. Conclusion: As a minimally invasive procedure, CSP is an effective treatment method for rapid, significant, and sustained pain reduction. [ABSTRACT FROM AUTHOR]

Objective: Non-adherence to pain medication is common in chronic pain patients and may result in unfavorable treatment outcomes. Interventions to improve adherence behavior often fail to significantly change medication use. In this report, we describe the application of a theoretical psychological model of behavior change in order to design an intervention to improve medication adherence in chronic pain patients.Methods: This study applies the Behavior Change Wheel framework and the Behavior Change Techniques Taxonomy to design a theory-based intervention to improve pain medication use. Available literature was used to extract determinants of adherence in chronic pain patients.Results: Selected target behaviors to improve medication adherence are: share agreement on follow up policy, monitor medication adherence, provide patient education routinely, discuss attitudes and concerns towards pain medication, develop medication taking habits and use medication reminders. The intervention consists of three components in which relevant behavior change techniques are applied: (1) changes in the electronic patient data management systems to enable medical staff to apply target behaviors; (2) bi-annual education of medical staff to commit the team to the proposed intervention and provide feedback; (3) routine and mandatory education of chronic pain patients following prescription of pain medication.Conclusions: To improve medication adherence in chronic pain patients, most interventions should be focused on providers of pain therapy. Prescribing chronic pain medication should be seen as part of a larger treatment regimen including adequate follow-up, adherence monitoring and patient education during the course of treatment. [ABSTRACT FROM AUTHOR]

The "gate control theory of pain" of 1965 became famous for integrating clinical observations and the understanding of spinal dorsal horn circuitry at that time into a testable model. Although it became rapidly clear that spinal circuitry is much more complex than that proposed by Melzack and Wall, their prediction of the clinical efficacy of transcutaneous electrical nerve stimulation and spinal cord stimulation has left an important clinical legacy also 50 years later. In the meantime, it has been recognized that the sensitivity of the nociceptive system can be decreased or increased and that this "gain control" can occur at peripheral, spinal, and supraspinal levels. The resulting changes in pain sensitivity can be rapidly reversible or persistent, highly localized or widespread. Profiling of spatio-temporal characteristics of altered pain sensitivity (evoked pain to mechanical and/or heat stimuli) allows implications on the mechanisms likely active in a given patient, including peripheral or central sensitization, intraspinal or descending inhibition. This hypothesis generation in the diagnostic process is an essential step towards a mechanism-based treatment of pain. The challenge now is to generate the rational basis of multimodal pain therapy algorithms by including profile-based stratification of patients into studies on efficacy of pharmacological and nonpharmacological treatment modalities. This review outlines the current evidence base for this approach. [ABSTRACT FROM AUTHOR]

Introduction and objective: In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically accompanied by severe, disabling pain. The objective of this study was to evaluate the feasibility of cement augmentation by RFS, as well as to determine postinterventional leakages and present the patients' outcomes. Material and method: In 20 patients (18 women, 2 men) with an average age of 80.4 (65-92) years, a fracture of the sacrum was detected by CT and MRI. Clinically manifest osteoporosis with QCT values of below 50 mg/ml was found in all patients. An initially performed conservative treatment over a period of 3 weeks did not achieve a satisfactory reduction in the severe, disabling pain. The cement augmentation was performed under CT guidance by means of RFS under intubation anaesthesia. A Jamshidi needle was advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. The highly viscous polymethyl methacrylate (PMMA) cement, activated by radiofrequency, was then inserted into the prepared fracture zone through a substituted screw cannula. Cement filling was performed discontinuously under instrumental guidance at 1.3 ml/min under CT guidance. Cement leakages were determined in CT images and conventional X-rays on the day after the intervention. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and after 6 and 12 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to state how satisfied they were after 12 months. Results: RFS was technically feasible in all patients. In the control CT scans and X-rays, sufficient cement distribution and interlocking with vital bone was found along the course of the fracture in the sacrum. 7.2 (4-9) ml of cement were inserted per fracture. Leakage could be ruled out. The mean pain score on the VAS was 8.8 ± 1.2 before the intervention, and a significant reduction in pain ( p < 0.001) was seen on the second postoperative day, with an average value of 2.3 ± 0.7, which was stable at 2.2 ± 1.3 after 6 months and 2.1 ± 1.1 after 12 months. All of the patients could be fully re-mobilised and discharged back home. A high level of patient satisfaction was found after 12 months, with 18 of the 20 patients stating that they would undergo the intervention again. One patient died of a stroke, another of cancer over the course. Conclusion: As a minimally invasive procedure, RFS is an effective and safe method of treatment for rapid, significant and sustained pain reduction. [ABSTRACT FROM AUTHOR]

Pain is the most common symptom of the disease that brings most patients to the doctor and is a sign of the existing or threatening organic or functional tissue damage. The first presentation is a case of chronic pain treatment caused as a result of the Herpes zoster virus that affected the intercostal region of the right side of the chest. Namely, the pain appeared immediately after the appearance of the first symptoms in the form of erythematous vesicular smallpox. The intensity of the pain increased and, in addition to organic damage to a part of the body with the formation of scars, created emotional instability in the sense of feelings of depression, insomnia and mood changes, with disbelief in the improvement of ailments as the end result. After three treatments at the Pain Therapy Outpatient Clinic, the patient felt an improvement in terms of reducing the intensity of pain, which also contributed to an emotional improvement in the form of a better mood, along with an improvement in the quality of life. In the second case, diabetic polyneuropathy affected the left calf and paresis of the n. peroneus which resulted in impaired mobility in the entire extremity. After few sessions, which included intra-articular blockages, the pain decreased and the mobility of the left column improved. In both cases, mutual great satisfaction and joy with the achieved results of intacostal and intra-articular blockade application was noticeable, and the motivation for further treatment and improvement of the quality of life with a reduction in the use of oral analgesics was stimulated. [ABSTRACT FROM AUTHOR]

The case of a 45-year-old male patient (body weight 52 kg, height 1.61 m) with a locally invasive gastric carcinoma infiltrating into the retroperitoneal space is reported. Because of severe cancer pain a tunnelled thoracic epidural catheter (EC) was placed at thoracic spinal level 7/8 and a local anesthetic (LA) mixture of bupivacaine 0.25 % and morphine 0.005 % was infused continuously at 6 ml h. To optimize pain therapy the concentration was doubled (bupivacaine 0.5 %, morphine 0.01 %) 3 months later but the infusion rate was reduced to 3 ml h thus the total daily dose did not change. The patient died 6 months after initiation of the epidural analgesia from the underlying disease. The total amount of bupivacaine infused was 69 g and of morphine 1.37 g. The patient never reported any neurological complications. The autopsy revealed large white crystalline deposits in the thoracic epidural space which were identified as bupivacaine base by infrared spectrometry. Morphine could not be detected. A histological examination showed unreactive fatty tissue necrosis within the crystalline deposits but nerve tissue could not be identified. It is concluded that the bupivacaine crystalline deposits arose due to precipitation but the clinical significance with regard to sensory level and neuraxial tissue toxicity is unknown. [ABSTRACT FROM AUTHOR]

Abstract: Modern forms of music therapy are clinically established for various therapeutic or rehabilitative goals, especially in the treatment of chronic pain. However, little is known about the neuronal mechanisms that underlie pain modulation by music. Therefore, we attempted to characterize the effects of music therapy on pain perception by comparing the effects of 2 different therapeutic concepts, referred to as receptive and entrainment methods, on cortical activity recorded by magnetencephalography in combination with laser heat pain. Listening to preferred music within the receptive method yielded a significant reduction of pain ratings associated with a significant power reduction of delta-band activity in the cingulate gyrus, which suggests that participants displaced their focus of attention away from the pain stimulus. On the other hand, listening to self-composed “pain music” and “healing music” within the entrainment method exerted major effects on gamma-band activity in primary and secondary somatosensory cortices. Pain music, in contrast to healing music, increased pain ratings in parallel with an increase in gamma-band activity in somatosensory brain structures. In conclusion, our data suggest that the 2 music therapy approaches operationalized in this study seem to modulate pain perception through at least 2 different mechanisms, involving changes of activity in the delta and gamma bands at different stages of the pain processing system. [Copyright &y& Elsevier]

The incidence of arthritis is increasing every year, as does the need for pain medication. The current work reviews an American Indian liniment that is traditionally used for pain therapy. The chemistry, therapeutic use and safety of the liniment are reviewed. The liniment contains monoterpenoids, sesquiterpenes, flavonoids, alkaloids and other compounds. [ABSTRACT FROM AUTHOR]

Hip replacement surgery is a common and effective procedure for the relief of pain and loss of function. The number of procedures is increasing and great interest is shown for the manner of outcome improvement following hip replacement surgery. Last decade (2001-2010) is declared as the Bone and Joint Decade and has been characterized by many innovations in hip replacement surgery including minimally invasive technique but also by improvements in anesthetic technique. However there is no consensus about most appropriate anesthetic and analgesic techniques to use. Total hip replacement is procedure characterized by great perioperative disturbances including cardiovascular complications, high incidence of thromboembolic complications, possible significant perioperative blood loss, possible bone cement effect and high level of postoperative pain. Anesthetic assessment of patients include preoperative preparations, intraoperative and postoperative care. Most important factors determining outcome of patients include preoperative assessment and planning in order to minimize potential anesthetic problems, optimize co-morbidity and provide the most appropriate anesthetic for the patient. In this article all problems of preoperative assessment are discussed. The recent data of advantages of regional anesthetic technique are outlined. All the problems of intraoperative course and how to avoid them are presented. The possible techniques of postoperative pain therapy are also presented. The importance of thromboprophylaxis is outlined and recent guidelines for thromboprophylaxis are given including recommendations for new antithrombotic drugs. Our recommendation is to always prepare a patient for this procedure, analyse preoperative status, choose optimal anesthetic technique, provide thromboprophylaxis and multimodal pain therapy according to accepted guidelines. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to demonstrate the usefulness of 2D multiplanar reformatting images (MPR) obtained from rotational acquisitions with cone-beam computed tomography technology during percutaneous extra-vascular spinal procedures performed in the angiography suite.Methods: We used a 3D rotational angiographic unit with a flat panel detector. MPR images were obtained from a rotational acquisition of 8 s (240 images at 30 fps), tube rotation of 180° and after post-processing of 5 s by a local work-station. Multislice CT (MSCT) is the best guidance system for spinal approaches permitting direct tomographic visualization of each spinal structure. Many operators, however, are trained with fluoroscopy, it is less expensive, allows real-time guidance, and in many centers the angiography suite is more frequently available for percutaneous procedures. We present our 6-year experience in fluoroscopy-guided spinal procedures, which were performed under different conditions using MPR images. We illustrate cases of vertebroplasty, epidural injections, selective foraminal nerve root block, facet block, percutaneous treatment of disc herniation and spine biopsy, all performed with the help of MPR images for guidance and control in the event of difficult or anatomically complex access.Results and Conclusion: The integrated use of "CT-like" MPR images allows the execution of spinal procedures under fluoroscopy guidance alone in all cases of dorso-lumbar access, with evident limitation of risks and complications, and without need for recourse to MSCT guidance, thus eliminating CT-room time (often bearing high diagnostic charges), and avoiding organizational problems for procedures that need, for example, combined use of a C-arm in the CT room. [ABSTRACT FROM AUTHOR]

Scientific studies have proven without doubt that an optimized perioperative pain therapy will improve patient comfort, reduce postoperative complications, enhance postoperative recovery and shorten the length of postoperative hospital stay. It is necessary to incorporate the acute pain therapy into a perioperative multimodal and interdisciplinary therapeutic concept. Local or regional anesthesia will provide the best analgesic effect after surgery and should be considered in all patients. Optimal treatment of patients with peripheral nerve blocks, spinal or epidural analgesia should be treated by a specialized acute pain service. However, only 15-20% of all surgical cases will be taken care of by such a pain service. Therefore, most surgical patients will only receive adequate analgesia if surgeons are familiar with the principles of postoperative pain therapy. Regular assessment of pain perception is the cornerstone of optimized pain therapy. Furthermore, pain assessment will allow the administration and to some extent dosage of analgesic therapy to be delegated to nursing personnel. [ABSTRACT FROM AUTHOR]

On March 15th 2010, Italy adopted the Law no. 38 ' Disposizioni per garantire l'accesso alle cure palliative e alla terapia del dolore' (Provisions aimed at ensuring access to palliative care and pain therapy). The aim of pain therapy is to enable patients with chronic diseases to achieve pain control. Palliative care, as defined by the World Health Organization, aims at 'improving the quality of life of patients and families, who face the problems associated with incurable diseases, through prevention and relief from suffering, achieved through an early identification and treatment of pain by pharmacological medication and other physical, psychosocial and spiritual techniques'. The main issues addressed by the law concern the monitoring of pain (the doctors will have to record on the clinical report form every level of pain intensity suffered by the patient, the appropriate therapy administered, and the pain relief achieved. This report must be kept accurately in all settings: hospital, day hospital and in outpatients). The law also suggests the establishment of two kinds of regional networks. One network (including Hospices) ensures the administration of palliative care to terminally ill patients; the other, including clinics and centers of pain therapy, provides assistance to patients with chronic pain. These networks involve general practitioners, hospital specialists and pain therapy specialists in order to ensure the best patient care. Simplification of the prescription of opiate drugs is also included in the law. In the prescription of opiates, the National Health Service medical staff can use the normal prescription form, and opiates will reimbursed by the NHS, like all other drugs. In addition, the technical papers provide precise indications of the appropriate modality of administration. The law allocates (art. 12, paragraph 2) 100 million euros per year and € 2,450,000 in the biennium 2010-2011 to implement experimental regional projects: 'hospital-territory without pain'. The Ministry of Health has established a deadline within which this law must be implemented at the regional level, and further establishes a specific National Observatory, an annual report on the use of drugs in the treatment of pain, and other provisions. The levels of spending by region will also be monitored in compliance with this law; university courses and masters are required to update professionals involved in pain treatment. In July 2010, in Florence, during the interdisciplinary IMPACT 2010 summit, Institutions and Scientific Societies met to define the concrete implementation of Law No. 38, in terms of the arrangements to ensure access to palliative care and pain management. Subsequently, last November, a new meeting was held bringing together medical directors from public hospitals; further meetings are planned with Regional Health Authorities to reaffirm the importance of this law and to implement it. The most important molecules in the opioids are traditionally divided into two groups: weak and strong. Among the strong analgesics are morphine, methadone, buprenorphine, fentanyl, oxycodone, hydromorphone. Among the weak are codeine and tramadol, or opiates administered at low doses, such as oxycodone combined with acetaminophen. IMPACT's aim is also to stimulate scientific association to consider with attention and continuous medical education on the appropriates of diagnosis and administration of these medications according to data flow sheets approved in Italy. Regarding the headaches, it should be noted that the law 38 cited above includes all forms of pain, and headaches should be integrated into the care networks. In this context, several multi-disciplinary professionals within the centers (hub and spoke) or territory (GPs, specialists from neurologists and other professionals involved) should be integrated to offer the best response to the needs of the citizen. The diagnosis and treatment of various forms of headache have to be integrated into the path of pain, both National and Regional, in line with the rest of the organization. [ABSTRACT FROM AUTHOR]

Capsicum species are not only cultivated as vegetable and condiment crops but are also incorporated into a number of medicinal preparations in the ancient literature around the world. ‘Naga chilli’ or ‘Bhoot Jolokia’ (Capsicum chinense Jacq.) is a chilli variety indigenous to the northeast region of India and has been recognized as the hottest chilli in the world. It has also been used conventionally in treating various human ailments since time immemorial by the indigenous people of the northeast India. Despite being an important crop of the northeast India, the information on the biology and cultivation of Naga chilli is very scanty and scattered. The present article reviews the scientific literature on above aspects with particular emphasis on identifying the key regional issues which need to be addressed urgently by the policy makers in order to harness its potential as an important source of capsaicinoids. Further, an attempt has been made to collate the potential of capsaicinoids in various ethnopharmacological applications such as pain therapy, body temperature regulation, anti-obesity treatments, anticancer therapy and as antioxidant and antimicrobial agent. We anticipate that this literature analysis of traditional medicinal uses and experimental trials of Capsicum using modern scientific approaches shall provide a basis for suggesting important areas where sincere research efforts are warranted to bridge the gap between traditional medicinal knowledge and modern biomedical knowledge. [Copyright &y& Elsevier]

The objective of this study was to determine if radiofrequency neurotomy is effective for patients with postoperative neck pain after cervical spine operations. The study design used was a retrospective practice audit. Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 2.5 years. Patients with persistent postsurgical neck pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). If pain recurred, diagnostic medial branch blocks were performed. Patients with at least 80% relief following both the therapeutic and the diagnostic block underwent radiofrequency neurotomy. Positive treatment response was defined for at least 50% reduction of pain or sufficiently satisfaction of the patient. Two hundred forty-two operations were performed, 125 of which were artificial disc operations, 66 were stand alone cages, and 51 were fusions with cage and plate. Two patients were lost to follow-up. Persistent neck pain occurred in 31% of the patients. The prevalence of zygapophysial pain after surgery was 13.2%. These 32 patients were treated with radiofrequency neurotomy because of recurrent neck pain. The average follow-up time was 15 months. A significant pain reduction was achieved in 59.4%. Significantly, after a double-level operation, more patients suffered persisting neck pain ( P = 0.002) compared with all patients being operated. Zygapophysial joints are a possible source of postoperative pain after anterior cervical spine surgery. Persistent and therapy-resistant neck pain occurs more often in patients after double-level operation. Radiofrequency neurotomy can provide an effective treatment for persistent neck pain after ventral cervical spine surgery. [ABSTRACT FROM AUTHOR]

Modern pain therapy widely follows the WHO (World Health Organization) guidelines using a three-step 'ladder' for pain relief. This escalating step scheme includes the administration in the order nonopioids, mild opioids and strong opioids, and adjuvants at any step. Analgesics should be given 'by the clock' rather than 'on demand'. However, the chronobiological parameters circadian pain rhythm, circadian efficacy of analgesics, and individual circadian need for analgesics are to be considered. The results of a multitude of studies in chronobiology are not consistent. Therefore, further studies with standardized protocols are needed that allow to assign more consistent rhythms to diseases, pain causes, and analgesic efficacy of opioids. In many cases, each patient perceives pain and its intensity individually during the time of day. By administration of analgesics over a constant or continuous dosage time fluctuations in pain perception and the outcomes of many studies in chronobiology are ignored that prove the influence of biological rhythms on the pharmacokinetic and pharmacodynamic aspects of analgesics. As different types of pain show different rhythms (highest pain intensities arising at different times of the day) analgesics should be dosed flexibly. It is also very important that drug therapy can be adjusted individually to the pain rhythm of the patient as well as to the type and cause of pain. In severe pain, therapy should be particularly careful. A flexible dosage depending on pain intensity and rapid dose adjustment are essentials of a modern pain therapy. Therefore, opioids that are flexible to use are better suited to treat the individual pain of the patient than rigid modified release oral or transdermal systems. [ABSTRACT FROM AUTHOR]

In February 2009 a major case of scientific misconduct was discovered. The American pain researcher Dr. S. Reuben had published 21 papers over a period of 15 years that were found to be fraudulent. Suddenly many advances in postoperative pain therapy which had been assumed to be correct seemed questionable. In this review article the lessons which can be learnt from this case are described. This review also reveals that it is almost impossible for reviewers or readers of scientific journals to detect scientific fraud. However, several warning signs can be identified that might be useful when reading clinical papers. In retrospect many of these signs were detectable in Reuben’s studies. Based on the fraudulent papers of Reuben it will be shown how and to what extent falsified results can affect other types of literature, such as practice guidelines, meta-analyses, review articles and oral presentations. [ABSTRACT FROM AUTHOR]

The share of ambulatory procedures is increasing with advances in operative and anesthesiological methods and pressured by economical necessities. Following legal regulations procedures with and without hospital stay underlie the same quality measures. Multimodal concepts comprising anesthesiological and operative procedures, pain therapy as well as postoperative care allow for quality improvements in respect to operative outcome and patient satisfaction. [ABSTRACT FROM AUTHOR]